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Fire Prevention
Programs
Resources
Burn Survivors
Programs
Camp Beyond the Scars
Burn Survivor Events
Applications
Our Impact
Get Involved
Donate Now
Ways to Give
Special Events
Volunteer
Internship
About Us
Our Mission
Our Team
Contact Us
News
Financials
Donate Now
Volunteer Sign Up
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Volunteer Sign Up
Family Retreat Volunteers Application
Part I. Volunteer Information
Name
*
First
Last
Mailing Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Email Address
*
Phone Number
*
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Occupation
Hidden
Have you ever worked with burn survivors before?
Yes
No
Hidden
Are you a new or returning volunteer for this retreat?
New
Returning
Hidden
Health Insurance Provider
Hidden
Primary Care Physician
Please list any allergies to food.
Hidden
Do you have any physical limitations or medical concerns? If so, please describe.
Hidden
Are you CPR/AED certified?
Yes
No
Hidden
CPR/AED Certification Expiration
Month
Day
Year
Hidden
CPR/AED Certification Type
Hidden
Are you First Aid certified?
Yes
No
Hidden
First Aid Certification Expiration
Month
Day
Year
Hidden
Do you have any other certifications that are applicable to this retreat?
Personal Background History
Have you ever been convicted, fined, place on probation or imprisoned?
Yes
No
Have you ever been accused of, convicted or of in any other way been involved in an allegation of a crime involving a child?
Yes
No
Have you ever been found liable for civil penalties or damages involving sexual or physical abuse of a child or children?
Yes
No
Are you now or have you ever been subject to any court order involving the sexual or physical abuse of a minor, including, but not limited to a domestic protection order or the termination of parent(s) guardian(s) rights?
Yes
No
Hidden
Name
First
Last
Hidden
Phone Number
Hidden
Relationship to You
Image, Video, and Information Release
WE REQUEST YOUR PERMISSION TO FILM, PHOTOGRAPH OR INTERVIEW YOU TO HELP OUR EFFORTS IN INCREASING PUBLIC AWARENESS AND SUPPORT OF OUR PROGRAMS BY APPEARING IN PHOTOGRAPHS, VIDEO OR OTHER PUBLICITY THAT THE RETREAT MAY PRODUCE.
Please Check Below
I DO AUTHORIZE THE BURN INSTITUTE TO USE PHOTOGRAPHS, VIDEOTAPES AND/OR INTERVIEWS OF ME TO FURTHER THEIR EFFORTS TO PROMOTE PUBLIC AWARENESS AND SUPPORT
I DO NOT WISH TO BE PHOTOGRAPHED/INTERVIEWED
THANK YOU!
We will be in touch about further steps! If you have any questions, please contact Leilani at
[email protected]
or 858-541-2277.
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